The National Provider Identifier (NPI) system uniquely identifies all healthcare providers in the United States. NPIs serve an important purpose on healthcare claims by ensuring provider information is accurate. According to those at Find-A-Code.com, performing an NPI lookup allows medical billers and coders to verify critical details about providers prior to claim submission.
What is the NPI System?
The NPI system stemmed from the 1996 Health Insurance Portability and Accountability Act’s (HIPAA) mandate to establish national standards for healthcare transactions. Rules finalized in 2004 required standard unique identifiers for providers, payers, and employers.
NPIs specifically apply to eligible individual healthcare providers like physicians, nurses, therapists, dentists, chiropractors, and other practitioners. They also cover healthcare facilities such as hospitals, nursing homes, residential treatment centers, clinical laboratories, ambulance companies, group practices, and more.
The 10-digit NPI has now fully replaced older legacy provider identifiers that varied across different health plans and insurance companies. This transition to a single national identifier system helps simplify data exchange.
NPIs are assigned by the Centers for Medicare & Medicaid Services (CMS) through an application process. Providers complete applications providing their credentials, taxonomy details, affiliations, and other data. This information is verified and then used to issue a single lifetime NPI that remains with that provider even if they change jobs, locations, or names.
Accurate provider NPIs are essential for processing claims, confirming benefits, managing referrals, coordinating care between facilities, transmitting prescriptions, and controlling access to medical records. They help link all of a provider’s information together unambiguously.
Core Provider Data Elements
An NPI lookup accesses a public database called the National Plan and Provider Enumeration System (NPPES). In addition to the 10-digit NPI, the database includes other core details about each registered provider such as:
- Legal names including doing-business-as (DBA) names
- Employer Identification Numbers (EINs)
- Addresses for all practice locations
- Phone, fax, email
- Provider type such as MD, RN, PT as well as taxonomy codes
- Medical specialties and credentials
- Hospital and nursing home affiliations
- Medical school and year of graduation
- Gender and date of birth
- License numbers, effective dates, and issuing states
- Medicare, Medicaid, and other payer IDs
Much of this data comes directly from the provider’s completed NPI application. However, some details like addresses and hospital affiliations may not always remain current after initial registration. Providers are responsible for updating their NPPES records if information changes.
How to Do an NPI Lookup
Multiple websites allow users to perform free NPI lookups. Typically, a coder just needs to enter some combination of an NPI, provider name, location, or taxonomy code to pull up matching records. Certain components like NPIs and addresses can also be validated through check digit calculations.
However, users must navigate these third-party NPI lookup tools carefully to isolate the correct provider record. It is best to search using as many distinct identifiers as possible retrieved from the claim documentation. Comparing multiple data points avoids mismatched records.
Any discrepancies between the NPPES record and the claim details should be addressed before filing. Coders may need to confirm which source is correct in order to submit accurate claims that won’t be rejected or denied.
Conclusion
Streamlined electronic claiming makes checking provider NPI details one of the primary ways coders can help minimize rejections. Taking a moment to lookup unfamiliar or questionable NPIs, confirm names/details, and check for red flags demonstrates a commitment to accuracy. After all, precision provider data is critical for clean claims, prompt reimbursements, and avoiding accusations of false or fraudulent billing. Performing a simple NPI lookup supports compliance, quality data, and efficient healthcare transactions.
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